Good Samaritan Nursing Home Operator, LLC

Based on complaint investigations, medical record reviews, and staff interviews, it was determined that the facility failed to assess and/or document the onset and management of unusual changes in resident condition. This deficiency was evident for one resident (Resident #153) out of three reviewed for injuries of unknown origin during the recertification/complaint survey.The findings include:On 4/30/26 at 8:00 AM, the surveyor reviewed self-reported incident #2720156. The report indicated that on 1/17/26, Resident #153 underwent an X-ray due to complaints of right hip pain, which revealed an acute fracture of the right femoral neck.At 8:34 AM on 4/30/26, a review of the resident's medical record revealed a Change in Condition note dated 1/17/26 at 1:33 PM. While the note acknowledged the X-ray results and the fracture, the record lacked any prior documentation regarding the resident's pain, including: the specific time of onset for the unusual pain, which staff member performed the initial clinical assessment, the interventions implemented to manage the pain while awaiting the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaint investigations, medical record reviews, and staff interviews, it was determined that the facility failed to ensure appropriate wound care, timely specialist consultation, and necessary medication adjustments. This was evident of one (Resident #157) out of five residents reviewed for pressure ulcers during the recertification/complaint survey.The findings include:Moisture-Associated Skin Damage (MASD) is an umbrella medical term for skin inflammation, irritation, and erosion (breakdown) caused by prolonged exposure to moisture, such as urine, stool, wound exudate, sweat, or saliva. A stage 2 pressure ulcer is a partial-thickness skin loss involving the epidermis and/or dermis, appearing as a shallow, pink/red, moist, open ulcer or a ruptured/intact blister. On 4/28/26 at 8:09 AM, the surveyor reviewed complaint regarding Resident #157. The review revealed that the complainant submitted on 1/09/26 had concerns regarding Resident #157's care: the resident did not receive appropriate care and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a complaint investigation, medical record reviews, and staff interviews, it was determined that the facility failed to ensure a resident received psychotropic medication as recommended by psychiatric consultants. This deficiency affected one resident (Resident #162) out of five reviewed for behavioral health during the recertification/complaint survey.The findings include:On 4/29/26 at 8:59 AM, the surveyor reviewed a complaint alleging that Resident #162 did not receive appropriate treatment for mental health issues during their stay at the facility.Further review of medical records for Resident #162 revealed that the resident was admitted to the facility on [DATE]. An initial psychological evaluation on 4/22/25 recommended Depakote 125 mg twice daily for mood and behavioral disturbances. Subsequent psychiatric consultations on 4/23/25 and 4/29/25 confirmed the ongoing need for this treatment.On 4/29/26 at 11:30 AM, a review of Resident #162's medication orders revealed that on 4/25/25, Depakote 125 mg…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations of the facility's kitchen and food services, it was determined that the facility failed to maintain sanitary food service operations. This deficiency was identified during multiple observations of kitchen and food service areas throughout the recertification/complaint survey. The findings include: During the initial tour of the kitchen on 4/27/26 at 7:50 AM, the surveyor noted a beverage cart containing apple juice, cups of milk, and cups of water that did not have dates marked on their lids. When asked how staff or residents would know when these beverages were prepared, Dietary Manager #25 stated, Everything in this kitchen is supposed to have a date. She then instructed a dietary aide to label the lids. On 4/28/26 at 7:28 AM, the surveyor inspected the nourishment rooms on the first floor. Accompanied by Geriatric Nursing Aide (GNA) #26, the surveyor found a paper bag containing food labeled with Resident #76's name in the refrigerator; however, it lacked a storage date. Additionally, the refrigerator contained an undated plate of cornbread and an unmarked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, it was determined that the facility failed to ensure that staff COVID-19 vaccination status was consistently monitored and documented. This was evident for 2 Geriatric Nurse Assistants (GNA) #18 and #9 of 5 randomly selected staff members reviewed during the recertification survey. The findings include: A COVID-19 vaccine is intended to provide acquired immunity against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease. On 5/01/2026 7:26 AM, a review of the employee health records for GNA #18 and #9 revealed no documented evidence of COVID-19 vaccination status.On 5/01/2026 at 8:04 AM, in an interview with the Assistant Director of Nursing (ADON), she stated that the facility offers COVID-19 vaccinations to all staff during on-site clinics; however, she acknowledged that vaccination status had not been consistently documented. On 5/01/2026 at 9:06 AM, the ADON provided an email correspondence with a community pharmacy indicating that 3 employees had expressed interest in receiving the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on an observation and facility staff interviews, it was determined that the kitchen failed to store food items, so as to maintain the integrity of the specific item. This was evident during the initial tour of the kitchen, by noting expired food items and undated opened items, observed by the surveyor during the recertification/complaint survey. The findings include: On 04/24/25 at 8:19 AM observations with the Food Service Director (FSD) revealed the following: In the kitchen dry storage room on at 8: 25 AM, Extra heavy half full one gallon Mayonnaise container without an open date. Several snack cups were on the floor under the storage shelves, Magic cup dessert, (2) vanilla (3) chocolate (2) and wild berry (1). Complete butter milk pan cake mix expired on 04/03/25. On 04/24/25 at 09:32 AM, the walk-in freezer had ice built up on the floor, noted hanging icicles under the condenser. Corn beef, wrapped in plastic wrap, was found in the kitchen fridge without an open date. On 04/24/25 at 09:06 AM Interview with dietary staff # 33 revealed that kitchen staff date the left over…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and an interview with Residents and staff, it was determined that the facility failed to maintain Residents' dignity as evidenced by 1) residents (Resident #14, #96, #30, #56) not being served meals at same time, and 2) Staff availability during the dining process to provide sufficient cueing, prompting, serving, and assisting residents to eat. This was evident for 1 of 2 dining observations performed at the main dining room with 5 large dining tables and 1 small dining table. The findings include: On 04/30/25 at 12:27 PM, an observation was made in the main dining room. Residents #14,# 96, #30, and #56 at table #1, were served their meals in the dining room [ROOM NUMBER] minutes after other residents were served their meals. Geriatric Nursing Assistant (GNA) staff # 28 sat at table #4, where she/he assisted Residents who sat at that table and socialized but did not offer assistance to residents at other tables. Resident # 19, with left-sided body weakness, sat in a wheelchair, seated at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews with facility staff and review of medical records, it was determined that the facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days of a resident's discontinuation from hospice services. This was evident for 1 (Resident # 30) of 47 residents reviewed during the facility's recertification/complaint survey. The findings include: The MDS is a federally mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. The information collected drives resident care planning decisions. MDS assessments need to be completed to ensure each resident receives the care they need. A Significant Change in Status Assessment (SCSA) is required when a resident enrolls in a hospice program or a resident receiving hospice services discontinues those services. On 4/24/25 at 10:01 AM review of Resident #30's medical record revealed the resident was admitted to the facility in June 2016. On 5/2/25 at 12:02 PM in an interview with the Regional Clinical Services Manager (RCSM #12) she stated that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of Minimum Data Set (MDS) Assessment documentation and an interview with facility staff, it was determined that the facility failed to complete discharge resident assessments as required. This finding was evident for 1 (Resident # 65) of 33 residents reviewed during the resident assessment task during the recertification/complaint survey. The findings included: The MDS is a federally mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. The information collected drives resident care planning decisions. Each assessment must be encoded within seven days and transmitted within fourteen days of the assessment being performed. On 05/01/25 at 11:44 AM, medical record review revealed that the resident # 65 was admitted for short-term rehab services to the facility on [DATE] and was discharged from the facility on 1/2/2025, in stable condition. Further review of the clinical record of resident #65 revealed no evidence that a discharge…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of the medical record and interviews with facility staff, it was determined that the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (Resident #2) of 47 residents reviewed during the facility's recertificaiton/complaint survey. The findings include: The MDS is a federally mandated assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. MDS assessments need to be accurate to ensure each resident receives the care they need. According to CMS's (Centers for Medicare & Medicaid Services) Resident Assessment Instrument (RAI) Version 3.0 Manual, the RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that: (1) the assessment accurately reflects the resident's status (2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical records and interview with facility staff, it was determined that the facility failed to ensure that residents were provided with summaries of their baseline care plans including a list of their medications. This was evident for 1 (Resident #67) of 47 residents reviewed during the facility's recertification/complaint survey. The findings include: A baseline care plan (BLCP) must be completed within 48 hours of a resident's admission to the facility and include the initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. A summary of the BLCP and medication list must be given to each resident and/or his/her representative. Completion and implementation of the BLCP is intended to promote continuity of care and communication among staff, increase resident safety, and safeguard against adverse events (undesirable outcomes) that can occur right after admission. On 4/28/25 at 9:11 AM, Resident #67's medical record was reviewed. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview with residents, surveyor observations, interview with facility staff, and review of medical records, it was determined that the facility failed to follow physician orders as evidenced by ensuring a resident's peripherally inserted central catheter (PICC line) dressing was changed as ordered by the physician. This was evident for 1 (Resident #67) of 47 residents reviewed during the facility's recertification/complaint survey. The findings include: A PICC line, or peripherally inserted central catheter, is a long, thin tube inserted into a vein in the arm and threaded up to a larger vein in the chest, near the heart. It provides long-term intravenous access for medications, fluids, blood draws, and other treatments. A PICC line requires careful care and monitoring for complications, including infections and blood clots. Dressings should be changed typically once a week, or sooner if they become wet, dirty, or loose as dressing changes are crucial for infection prevention. On 4/24/25 at 9:44 AM in an interview with Resident #67, s/he stated s/he was getting IV…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, medical record review, and interview, it was determined the facility staff failed to provide adequate care to prevent complications from hand contractures. This was evident for 1 (#83) of 3 residents reviewed for limited range of motion (ROM) during a recertification/complaint survey. The findings include: A contracture is an abnormal shortening of muscle tissue causing the muscle to be resistant to stretching. Failure to protect the palm of the hand when the hand is contracted can result in injury to the palm of the hand caused by the pressure of fingers/fingernails pressing into the palm of the hand. Observation of Resident #83 on 4/25/2025 at 9:15 AM revealed that the resident's left hand was contracted. The resident's fingers were bent inwards and nails pressing into the palm of the resident's hand. When instructed to open their left palm, Resident #83 stated s/he could not do so. The resident did not have a protective device (palm protector/splint) to prevent pressure to their palm, and none was visible in their room. The observation was brought to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, medical record review, and interview, it was determined the facility staff failed to 1) label oxygen tubing and humidifier bottle when changed, and 2) equip a resident with an incentive spirometer to address their respiratory needs per physicians order. This was evident for 2 (#45, #67) of 3 residents reviewed for respiratory care during a recertification/complaint survey. The findings include: Oxygen (O2) therapy is a treatment that provides you with extra oxygen to breathe in. It is also called supplemental oxygen. It is only available through a prescription from your health care provider. An incentive spirometer is a simple, plastic medical device that exercises your lungs. Your healthcare provider may recommend that you use an incentive spirometer after an illness, surgery or an injury to your chest or abdomen. An incentive spirometer helps prevent lung infections by expanding your lungs, strengthening your lungs, keeping your lungs inflated and clearing mucus and other secretions. You may have low oxygen levels after surgery or a serious illness, and an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews with residents and staff and medical record reviews, it was determined the facility failed to ensure that residents were given pain medications timely and consistent with professional standards of practice. This was evident for 2 ( #237, #37) of 4 residents reviewed for pain management during a recertification/complaint survey. The findings include: 1) On 4/24/25 at 11:10 AM during the initial tour of the facility, Resident #237 told the surveyor that s/he was not sure if their pain medication was ordered as needed or scheduled because they were not getting it on time. Review of the Physicians' order on 4/28/25 at 11:59 AM had orders written as: 4/19/25: Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) *Controlled Drug* Give 2 tablet by mouth at bedtime for Back pain. 4/20/25: Acetaminophen Oral Tablet 500 MG (Acetaminophen), Give 1 tablet by mouth at bedtime for pain Do not exceed 3 gm in 24 hours. On 4/28/25 at 1:50 PM a review of the facilities medication administration policy had under #5 that medication passes must be started no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview with residents, review of medical records, and interviews with facility staff, it was determined that the facility staff failed to ensure that residents who require dental services on a routine or emergent basis receive necessary or recommended dental services in a timely manner. This was evident for 1 (Resident #67) of 47 residents reviewed during the facility's recertification/complaint survey. The findings include: Resident #67 was interviewed on 4/24/25 at 10:06 AM. During the interview s/he stated s/he was missing some teeth, and it was causing him/her pain and discomfort. Resident #67 opened his/her mouth to show the surveyor. The surveyor observed several missing and/or jagged teeth. Additionally, s/he stated that x-rays were taken, but s/he had not heard anything after that and was waiting for a follow up appointment with the dentist. On 4/29/25 at 8:05 AM review of Resident #67's medical record revealed the following dental notes: - 2/10/25 Dentist Note: The Tooth Grid of the dental note revealed the resident had 9 missing teeth, 2 non-restorable teeth, 3…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on a complaint, record review, resident and staff interviews, it was determined the facility failed to develop, prepare, and distribute menus that reflect a resident's nutritional wishes. This was evident for 1 (#37) of 2 residents reviewed for food during a recertification/complaint survey. The findings include: In an interview with Resident #37 on 4/24/2025 at 9:05 AM, the Resident stated that the food served did not match what was on the meal ticket. Resident #37 stated that s/he was allergic to pork but they served her/him pork sausage and bacon. Resident #37 further stated that s/he did not eat corn because of a medical condition but they served her/him corn even though the meal ticket indicated no pork and no corn. Review of Resident #37's clinical records on 4/29/2025 at 10:42 AM revealed the resident had allergies that include but not limited to Corn and Pork. An interview was conducted with the Registered Dietitian (RD #7) on 5/2/2025 at 9:13 AM: Regarding Resident #37's food concerns, RD #7 stated they were aware that the resident was served food items (pork and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records review and interviews during a complaint survey, the facility did not ensure each resident had the right to participate in the development and implementation of their person-centered plan of care, including to participate in the planning process and to request meetings for one resident (Resident # 8) out of three residents reviewed for resident rights. Specifically, the facility did not schedule quarterly case plan conferences to evaluate Resident #8's plan of care and to allow for the resident's representative to participate in plan of care decision making. The findings include: The facility's policy and procedure titled Assessment of Resident: Comprehensive Care Planning Process, (last revised June 2024), read in part that the purpose of the policy is to ensure that the best approaches to provide for the quality of care for each resident were developed, implemented and evaluated and to assure that care planning was performed in a timely manner. Participants in the care planning process were to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during a complaint survey the facility failed to ensure the resident environment remained free of accident hazards and adequate supervision was provided to prevent accidents for one resident (Resident #10) out of five residents reviewed for accidents/hazards. Specifically, for Resident #10 the facility failed to ensure the following: new interventions were implemented to prevent accidents after the resident had a fall on 2/3/2022 and sustained a laceration to their head; fall care plan was followed; was not left unattended on their side while they were being changed which resulted in a fall; and the behavioral care plan was followed for staff to not leave plastic items within reach of the resident; this created an environmental hazard due to the resident ' s behavior of eating plastic. The findings include: The facility ' s Fall Prevention/ Management Program and Incident/ Accident Management Policy, last revised June 2005, documented once a resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview, it was determined that the facility staff failed to ensure a resident was administered medication according to parameters (#73). This was evident for 1 out of the 5 residents reviewed for unnecessary medications. The findings include: A review of Resident #73's clinical record on 7/9/21 at 10:38 AM revealed the resident was ordered Humalog 100 units/ml inject 15 units, subcutaneously with meals, and to hold if fingerstick is less than 110. A review of the Resident #73's Medication Administration Records (MAR) for June and July 2021 revealed that the resident had fingersticks below 110 but was administered the medication on these dates and times: 6/3/21 at 6:30 AM, 6/12/21 at 6:30 AM, 6/15/21 at 6:30 AM, 6/29/21 at 6:30 AM, 7/1/21 at 6:30 AM, 7/1/21 at 4:30 PM, 7/8/21 at 4:30 PM, 7/9/21 at 6:30 AM, 7/10/21 at 4:30 PM, and 7/13/21 at 6:30 AM. The Director of Nursing (DON) was interviewed on 7/14/21 at 8:05 AM. She was shown the MAR's and the coding of the MAR was discussed. She said that when staff code a medication administration…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and review of medical records, it was determined that the facility staff failed to provide showers to the resident as per preference and request. This was found to be evident for 1 (Resident #88) out of the 1 residents reviewed during the survey. The findings include: The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. The MDS is a multi-disciplinarian tool that allows many facets of the resident's care [cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain and medications to name a few] to be addressed. The findings include: On 7/8/2021 at 7:18 AM, Resident #88 was asked about his/her choices related to bathing, and questioned if s/he received showers. S/he shook his/her head left to right. Surveyor confirmed with Resident # 88 that s/he meant 'no.' S/he then stated that s/he only gets bed baths. Resident #88 was then asked if s/he would like to receive showers and s/he indicated 'yes.' Review of Resident #88's medical record, on 7/8/2021 at 11:13 AM, revealed a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of resident council meeting minutes, residents and staff interview, it was determined that the facility staff failed to give adequate responses to grievances presented by the resident council. This was found evident for 3 of 8 months of resident council meeting minutes and facility responses reviewed during the survey. The findings include: On 7/8/2021 at 1:50 PM, the surveyor interviewed the Activity Director (Staff # 17), who stated that there were no group meetings during the pandemic. However, the residents were given a sheet (Resident Council Precautionary Isolation Questionnaire) for them to submit their concerns/grievances. The first group meeting post pandemic was held on 6/22/2021. On 7/9/2021 at 7:30 AM, a review of the resident council meeting minutes on the resident council Precautionary Isolation Questionnaire form revealed documentation of repeat concerns regarding some in- room phones having a very low volume and clothes returning late from the laundry. The concerns related to the phones was noted on the November 2020 resident council Precautionary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review, and staff interview, it was determined that the facility staff failed to ensure that residents who were dependent on staff for activities of daily living (ADL) had their toenails trimmed. This was evident for 2 (#64 and #79) out of 5 residents reviewed for ADL care. The findings are: 1. Observation of Resident #64 on 7/7/21 at 11:22 AM revealed resident to be in bed with both feet exposed. The resident's toenails were elongated, thick, and yellow. Observations were made on 7/12/21 at 1:42 PM, 7/13/21 at 11:20 AM, and 7/14/21 at 2:13 PM, and the toenails were elongated, thick, and yellow. Resident #64's clinical record was reviewed on 7/14/21 and their last podiatry appointment was documented as 3/3/21. Interviewed the unit manager (Staff #21) was conducted on 7/14/21 at 2:15 PM and she was shown the resident's toenails. She said the podiatrist comes every two months and agreed that the resident's toenails needed to be trimmed. This surveyor interviewed the regional clinical services manager (Staff #4) on 7/15/21 at 8:18 AM. He was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with facility staff, it was determined that the facility failed to have a consistent process in place to ensure that the computer and the physician orders consistently referred to the correct Maryland Order of Life Sustaining Treatments (MOLST). This was evident for 3 of 4 residents (#25, #69 and #38) reviewed during the initial review of residents during the annual survey. The findings include: MOLST (Maryland Medical Orders for Life-Sustaining Treatment) is a form which includes medical orders for emergency medical services or other medical personnel regarding CPR (cardiopulmonary resuscitation) and other life sustaining treatment options. 1. Review of the medical record for Resident #25 on [DATE] at 9:44 AM revealed a notation in the electronic health record (EHR) under the resident's picture, date of birth and allergies noted: 'See MOLST dated [DATE].' However, according to the physician orders, it states 'See MOLST' dated [DATE]. A review of Resident #25's paper…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.